HomeMy WebLinkAboutSeptic Pumping Slip - 46 Wintergreen - Septic Pumping Slip - 46 WINTERGREEN DRIVE 10/18/2024 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
HOUSE: front- a?"de rear eft' right
A. Facility Information ~ BUILDING: front back side rear left right
Important:When DECK: under
filling out forms 1. System Location:
on the computer,
use only the tab 4
e ��" 4\
key to move your Addr ss 1j
cursor-do not MA
use the return
key. City/Town —Zip Code
2, Syste Owner:
Name
Address(-I-f,different f-ro-rn--I-o—c-s-'t —-----
MA
11,lode
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Gallons
3. Component: Cesspool(s) Septic Tank 7 Tight Tank 7 Grease Trap
[I Other(describe):
4. Effluent Tee Filter present? 7 Yes No If yes, was it cleaned? ❑ Yes 7 No
5. Observed condition of component pumped:
6. System Pumped By:
_gave Tiney Mass 1AA95E I' ass` �A b-31-Z
Name Vehicle License Number
Bateson Enterprises, Inc.
Company
7. 7tion where contents were disposed:
GL IS D�
Signature of Hauler Date
Signature of Receiving Facility(or attach faailiky receipt) Date
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